Pennsylvania Department of Health
FOX SUBACUTE AT MECHANICSBURG
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

FOX SUBACUTE AT MECHANICSBURG
Inspection Results For:

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FOX SUBACUTE AT MECHANICSBURG - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights survey completed on January 22, 2026, it was determined that Fox Subacute at Mechanicsburg was not in compliance with the following requirements of 42 CFR Part 483 Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.10(c) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

§483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

§483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

§483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to discuss the risks/benefits and obtain consent for psychotropic medications for two of two resident records reviewed (Residents 48 and 49).

Findings include:

Review of Resident 48's clinical record revealed diagnoses that included major depressive disorder severe with psychotic features (a severe form of depression characterized by the presence of psychotic symptoms, such as hallucinations or delusions, alongside typical depressive symptoms) and generalized anxiety disorder (a mental health condition that causes fear, a constant feeling of being overwhelmed and excessive worry about everyday things).

Review of Resident 48's physician's orders revealed the use of quetiapine (an antipsychotic medication) with an ordered date of April 15, 2025; and lorazepam (an antianxiety medication) with an ordered date of October 17, 2025.

Review of Resident 48's physician order history revealed that he had been on these types of medications since January 24, 2025.

Review of Resident 48's clinical record revealed a "Psychotropic Medication Treatment Consent", which indicated that Resident 48 was being treated for "Tracheotomy/Brain Damage" and the medications being used line was blank. The consent was signed by Resident 48's Representative on September 9, 2024.

Further review of Resident 48's clinical record failed to reveal any documentation of the facility providing education to the Resident or Representative of the risks and benefits associated with the use of the antipsychotic and antianxiety medications, including side effects and other adverse reactions.

Review of Resident 49's clinical record revealed diagnoses that included schizoaffective disorder bipolar type (schizoaffective disorder is a mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression, mania and a milder form of mania called hypomania; bipolar type includes bouts of hypomania or mania and sometimes major depression), generalized anxiety disorder, and major depressive disorder.

Review of Resident 49's physician's orders revealed the use of olanzapine (an antipsychotic medication) with an ordered date of March 5, 2024; buspirone (an antianxiety medication) with an ordered date of October 23, 2025; and escitalopram (an antidepressant medication) with an ordered date of July 30, 2025.

Review of Resident 49's clinical record revealed a "Psychotropic Medication Treatment Consent", which revealed that the condition Resident 49 was being treated for and the medications being used were blank. The consent was signed by Resident 49's Representative on July 16, 2021.

Further review of Resident 49's clinical record failed to reveal any documentation of the facility providing education to Resident 49 or his Representative of the risks and benefits associated with the use of the antipsychotic, antianxiety, or antidepressant medications, including side effects and other adverse reactions.

During a staff interview with the Nursing Home Administrator (NHA) and the Director of Nursing on January 22, 2026, at 11:20 AM, the NHA indicated that the facility practice was to have the Resident or their Representative sign the "Psychotropic Medication Treatment Consent" as part of the admission process to the facility. He further indicated that the facility practice was not to get another consent signed. He said that staff would review with a Resident's Representative any medication changes and would document this discussion in the progress notes.

As of January 22, 2026, at 1:15 PM, the facility had not provided any additional information to indicate that Resident 48's and 49's Representatives had been informed of the risks and benefits associated with the use of their ordered psychotropic medications, including side effects and other adverse reactions, at time of admission to the facility or when medication/treatment changes occurred.

28 Pa. Code 201.29 Resident rights.

Plan of Correction - To be completed: 03/09/2026

Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

One: actions taken for situation identified:
1) The Facility recognizes that it cannot retroactively correct the situation for resident R48 and R49.
2) The Facility will review consents for all current residents on psychotropic medications.
3) All current residents will have updated and specific consents for all psychotropic medications where applicable.
Two: how the facility will respond regarding residents in similar situations:
The facility recognizes that all residents have the potential to be affected. Please see sections three and four for system changes and monitoring mechanisms.
Three: system changes and measures that will be taken:
1) All Licensed staff will be in-serviced on the requirement of consent, risk vs benefit education and documentation of each for any psychotropic medication orders.
2) Changes and initiations of new psychotropic medication orders will be discussed at Daily Clinical meetings and documentation will be checked as necessary for corrections.
Four: monitoring mechanism to assure compliance:
1) The Director of Nursing or her designee will conduct audits on ten (10) random residents for 4 weeks for compliance with consents and documentation, then five (5) random residents weekly for 2 months.
2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:

§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Observations:

Based on clinical record review, facility policy review, and staff interview, it was determined that the facility failed to ensure Medication Regimen Reviews were reviewed and responded to by the attending physician or prescriber for three of six residents reviewed (Residents 3, 6, and 15).

Findings include:

Review of facility policy, titled Medication Regimen Review (Monthly Report), without revision date, revealed, "Recommendations are acted upon and documented by the facility staff and or the prescriber."
Review of Resident 3's clinical record revealed diagnoses that included heart failure (the heart can't pump enough oxygen-rich blood to meet the body's needs, causing symptoms like shortness of breath, fatigue, and swelling; often from underlying issues like high blood pressure or coronary artery disease) and respiratory failure (a serious condition where the lungs can't adequately oxygenate the blood or remove carbon dioxide).

Review of Resident 3's medical record revealed a recommendation made on December 10, 2025, by the consultant pharmacist to add additional monitoring for Resident 3's anticonvulsant medication. Further review of the document revealed that it was signed by a nurse along with the statement, "added to order", with no physician signature. Further review of the record failed to reveal that the physician had reviewed or taken action to address the irregularity.

Review of Resident 6's clinical record revealed diagnoses that included heart failure and respiratory failure.

Review of Resident 6's medical record revealed a recommendation made on October 17, 2025, by the consultant pharmacist to either add limit of 14 days to Resident 6's PRN (as needed) antianxiety medication or provide a rationale for extending the order and indicate a duration for the order. Further review of the document revealed that it was signed by a nurse along with the statement, "14-day added to order", with no physician signature. Further review of the record failed to reveal that the physician had reviewed or taken action to address the irregularity.

Review of Resident 15's clinical record revealed diagnoses that included fracture of first thoracic vertebra (a break in the first thoracic vertebra, located at the top of the mid-back, often caused by significant trauma like car accidents or falls, and can lead to severe neck/back pain, potential spinal cord injury, hand weakness/numbness, and even quadriplegia if nerves are damaged) and respiratory failure.

Review of Resident 15's medical record revealed a recommendation made on December 10, 2025, by the consultant pharmacist to add additional monitoring for Resident 15's antipsychotic medication. Further review of the document revealed that it was signed by a nurse along with the statement, "AIMS (Abnormal Involuntary Movement Scale- a scale to assess severity of involuntary facial movements in patients taking certain medications)", with no physician signature. Further review of the record failed to reveal that the physician had reviewed or taken action to address the irregularity.

Interview with the Director of Nursing on January 22, 2026, at 10:45 AM, revealed that they would expect the regulation to be followed.

28 Pa. Code 211.10(c) Resident care policies.

Plan of Correction - To be completed: 03/09/2026

Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

One: actions taken for situation identified:
1) The Facility recognizes that it cannot retroactively correct the situation for resident R3, R6 and R7.
2) All Pharmacy Nursing Recommendations beginning January 2026 will be reviewed and signed by the medical provide
3) Physician reviewed the recommendations for R3, R6, and R7 and agreed with the recommendations and signed off on them
Two: system changes and measures that will be taken:
1) The DON, ADON and Medical Director will be in-serviced on the requirement of medical provider approval and signature prior to initiating Nursing Measure Recommendations.
2) All Pharmacy Nursing Recommendations will await a medical provider signature before being implemented.
3) All Pharmacy Nursing Recommendations beginning January 2026 will be signed off by the medical provider
Three: monitoring mechanism to assure compliance:
1) The Director of Nursing or her designee will conduct random audits on 10 (10) random residents for 4 weeks for compliance with pharmacy Nursing Recommendations, then five (5) random residents weekly for 3 months.
all pharmacy Nursing Recommendations as received from Pharmacy to ensure recommendations are signed off by the medical provider.
2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Observations:

Based on facility policy review, clinical record review, observation, and staff interviews, it was determined that the facility failed to ensure that the care plan was reviewed and revised to reflect the resident's current status for two of 12 residents reviewed (Residents 1 and 4).

Findings include:

Review of facility policy, titled "Care Plan and Conference," last reviewed December 31, 2025, read, in part, "Purpose: To facilitate communication of all disciplines of pertinent patient information to formulate a useful care plan that will drive patient care and improve outcomes. Procedure: Ongoing communication between nursing and the Registered Nurse Assessment Coordinator will occur with any change in resident condition."

Review of Resident 1's clinical record revealed diagnoses that included chronic respiratory failure (lungs cannot get enough oxygen into the blood or remove enough carbon dioxide) and dependence on a respirator (unable to breath independently and relies on a machine for life sustaining respiration).

Review of Resident 1's physician orders revealed an order for trach type and size: # 8 Portex, with a start date of March 19, 2025.

Review of Resident 1's comprehensive plan of care revealed a care area for ineffective airway clearance related to disease process with vent support as needed and trach. Trach type and size: 7 XLT-D cuffed.

Interview on January 22, 2026 at 10:46 AM, with the Nursing Home Administrator and Director of Nursing (DON) revealed Resident 1's trach size and type changed and her care plan was not updated. The DON stated she would expect care plans to be updated timely.

Review of Resident 4's clinical record revealed diagnoses that included chronic respiratory failure and hypertension (persistent high blood pressure).

Review of Resident 4's clinical record revealed he had an unwitnessed fall on September 24, 2025.

Review of Resident 4's fall report from September 24, 2025, revealed an intervention to place bilateral fall mats on either side of his bed.

Review of Resident 4's comprehensive care plan revealed a focus area for "At risk for falls" with an intervention for "bilateralfallmats - ensure placement every shift," last revised October 21, 2025.

Observation in Resident 4's room on January 20, 2026, at 11:03 AM; and January 21, 2026, at 12:58 PM, failed to reveal bilateral fall mats.

Interview with Employee 4 (Housekeeper) on January 21, 2026, at 12:58 PM, revealed she hasn't seen any fall mats in the Resident's room.

During an interview with the DON on January 21, 2026, at 1:03 PM, she revealed the fall mats had previously been reviewed and discontinued.

Follow up interview with the DON on January 22, 2026, at 11:27 AM, revealed the fall mats were reviewed and discontinued around the time of his most recent hospitalization in November 2025, and she would expect his care plan to be updated. The DON stated she would expect care plans to be updated timely.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.11(d)(3)(5) Nursing services

Plan of Correction - To be completed: 03/09/2026

Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

One: actions taken for situation identified:
1) The Facility recognizes that it cannot retroactively correct the situation for resident R1 and R4.
2) The Facility updated R1, and R4 care plans to reflect current resident orders and plan of care.
3) All resident care plans were reviewed to ensure that care plans reflect current resident orders and plan of care.
Two: system changes and measures that will be taken:
1) All Licensed and IDC staff will be in-serviced on initiating, updating and resolving care plan items.
2) Care plans will be monitored at Daily Clinical meetings and updated as necessary
Three: monitoring mechanism to assure compliance:
1) The Director of Nursing or her designee will conduct audits on 5 (5) random residents 3x week for 4 weeks for compliance with care plans, then five (5) random residents 1x week for 2 months.
2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:

§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.

Observations:

Based on facility policy review, observation, clinical record review, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for one of three residents observed during medication administration pass (Resident 46).

Findings include:

Review of facility policy, titled "Medication Administration," dated November 30, 2025, with a last review date of December 31, 2025, revealed, in part, that "gastrostomy tube [a flexible feeding tube placed through the abdominal wall and into the stomach which allows nutrition to be placed directly into the stomach] placement will be confirmed by auscultation with air" prior to medication administration.

Review of Resident 46's clinical record revealed diagnoses that included acute and chronic respiratory failure with hypoxia (the inability of the respiratory system to meet the oxygenation requirements of the body, dependence on a ventilator, and presence of gastrostomy tube.

Review of Resident 46's physician orders revealed an order for "Confirmation of feeding tube placement to be done prior to every instillation of tube feeding, medications, water, ect. every shift. Confirm placement per policy," dated January 8, 2026.

During a medication administration observation for Resident 46 on January 22, 2026, at 8:45 AM, Employee 3 (Registered Nurse) was observed to administer Resident 46's medications through the Resident's gastrostomy. Employee 3 failed to confirm placement of the gastrostomy tube prior to administering the medications.

During a staff interview with Employee 3 on January 22, 2026, at 8:55 AM, Employee 3 indicated that the facility used to have a policy in place that indicated gastrostomy tube placement was to be verified before medication administration, but Employee 3 believed that was no longer in effect.

During a staff interview with the Nursing Home Administrator and Director of Nursing (DON) on January 22, 2026, at 11:39 AM, the DON confirmed that Employee 3 should have verified Resident 46's gastrostomy tube placement before administering the medications.

28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Plan of Correction - To be completed: 03/09/2026

Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

One: actions taken for situation identified:
1) The Facility recognizes that it cannot retroactively correct the situation for resident R46.
2) Employee 3 was educated on Policy for Med Administration – PEG tubes.
3) All current residents with PEG tubes were reviewed for inclusion of the 'Confirmation of placement before med instillation' order.
Two: system changes and measures that will be taken:
1) All Licensed staff will be in-serviced on Medication Administration Policy regarding PEG tubes.
2) All Licensed staff will be in-serviced on how to check PEG placement.
Three: monitoring mechanism to assure compliance:
1) The Director of Nursing or her designee will conduct audits on 5 random residents 3x a week for 4 weeks for compliance with PEG tube placement checks prior to medication instillation, then five (5) random residents 1x week for 2 months.
2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for one of two residents reviewed for pressure ulcers (Resident 4).

Findings include:

Review of facility policy, titled "Wound Care and Pressure Ulcer Care" last reviewed December 31, 2025, read, in part, "Purpose: To manage wounds and or pressure ulcers and promote patient comfort. Check the doctor's order for specific wound care and medication instructions."

Review of Resident 4's clinical record revealed diagnoses that included pressure ulcer of other site, stage 3 (injury to the skin and underlying tissue caused by prolonged pressure on the skin), chronic respiratory failure (lungs cannot get enough oxygen into the blood or remove enough carbon dioxide), and hypertension (high blood pressure).

Review of facility documents, titled "Wound Evaluation &; Management Summary" dated October 27, 2025; November 7, 2025; November 10, 2025; December 1, 2025; December 8, 2025; December 19, 2025; December 22, 2025; January 5, 2026; January 12, 2026; and January 19, 2026; note "Specific to visit recommendations: Dietician consult, vitamin C 500 mg BID (twice daily)."

Review of dietitian notes, titled "Weekly Wound Meeting" dated October 28, 2025; November 13, 2025; December 2, 2025; December 9, 2025; December 19, 2025; December 23, 2025; January 6, 2026; and January 13, 2026; note Resident 4 is taking vitamin C as an intervention for wound healing.

Review of Resident 4's physician orders revealed an order for "Ascorbic Acid (Vitamin C) Oral Tablet 500 MG, Give 500 mg two times a day for wounds," with a start date of September 18, 2025, and a discontinued date of October 6, 2025.

During an interview with the Director of Nursing on January 22, 2026, at 12:26 PM, she revealed the vitamin C order for Resident 4 was discontinued when he went to the hospital on October 5, 2025, and never got reentered when he returned. She further revealed the order should have been reinstated when he returned from the hospital as it was still recommended by the wound doctor, and she would expect physician recommendations to be implemented.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(c)(d) Resident care policies
28 Pa. Code 211.11(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 03/09/2026

Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

One: actions taken for situation identified:
1) The Facility recognizes that it cannot retroactively correct the situation for resident R4.
2) All current residents receiving wound services with the VOHRA wound provider will have the most recent rounding notes reviewed for any missing recommendations.
Two: system changes and measures that will be taken:
1) The wound Nurse will be in-serviced on thorough review of wound provider notes to ensure all recommendations are forwarded to the Medical Director if not already in place.
2) Wound round recommendations will be reviewed at Daily Clinical meetings for IDT team to confirm resident orders where applicable.
Three: monitoring mechanism to assure compliance:
1) The Director of Nursing or her designee will conduct audits on 5 random wound residents 3x a week for 4 weeks for compliance with wound provider recommendations, then five (5) random residents 1x week for 2 months. Any recommendations not endorsed by the Medical Director will be documented as such.
2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to label medications properly and failed to discard expired medications in one of two medication rooms observed (First Floor Medication Room).

Findings include:

Review of facility policy, titled "Pharmacy Services," dated November 28, 2018, with a last review date of December 31, 2025, revealed, in part, "All opened multi-dose vials will be dated at the time that they are opened."

Review of tuberculin skin testing solution informationrevealed that tuberculin skin testing solution expires 30 days after the initial puncture into the vial.

Observation of the First Floor Medication Room with Employee 1 on January 21, 2026, at 8:54 AM, revealed two opened vials of tuberculin skin testing solution. One bottle had no open date noted and the other vial was dated December 4, 2025.

During a staff interview with the Director of Nursing (DON) and the Assistant Director of Nursing on January 21, 2026, at 9:20 AM, the DON acknowledged multi-dose vials should be dated when opened and confirmed that the tuberculin skin testing solution vial dated with an open date of December 4, 2025, was expired and should have been discarded.

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 211.9(a)(1) Pharmacy services.
28 Pa. Code 211.12(d)(1)(2)(3) Nursing services.

Plan of Correction - To be completed: 03/09/2026

Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

One: actions taken for situation identified:
1) The Facility recognizes that it cannot retroactively correct the situation for First Floor Med Room expired medication and undated vial.
2) The Facility reviewed all medication rooms for expired medications and undated opened vials.
3) All current medication rooms are free of expired medications. All opened medications requiring dates are dated.
Two: system changes and measures that will be taken:
1) All Licensed staff will be in-serviced on Proper Medication storage and labeling per policy, that only one vial should be opened at a time and dated upon opening. All expired meds should be disposed of per policy.
Three: monitoring mechanism to assure compliance:
1) The Director of Nursing or her designee will conduct audits on all three Medication Storage Rooms once a week for 4 weeks for compliance, then once a month for 2 months.
2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on observation and staff interviews, it was determined that the facility failed to maintain an effective infection control program related to the administration of medications for one of three residents observed during medication administration observation (Resident 33).

Findings include:

Observation of Resident 33's medication administration by Employee 2 on January 21, 2026, at 10:05 AM, revealed Employee 2 donned her gown and gloves upon entering Resident 33's room. Employee 2 sat Resident 33's cups of prepared medications down on the heating unit. Employee 2 was then observed to use both of her gloved hands to pick the fall mat up off the floor on the left side of the bed and lean it against the wall. Employee 2 then placed Resident 33's cups of prepared medications on top of the upright fall mat that she had placed against the wall. Employee 2 then proceeded to administer Resident 33's medications via her gastrostomy tube (a flexible feeding tube placed through the abdominal wall and into the stomach, which allows nutrition to be placed directly into the stomach). During the continued process of administering Resident 33's medications, Employee 2 was also noted to be holding the end of the tube feeding administration tubing that connects directly to the gastrostomy tube inside her left gloved hand.

During an immediate staff interview with Employee 2 on January 21, 2026, at approximately 10:20 AM, Employee 2 confirmed that she had used her gloves to touch the fall mat that was on the floor and proceeded to administer the medications. Employee 2 acknowledged that she should have removed her gloves, cleansed her hands, and applied clean gloves.

During a staff interview with the Nursing Home Administrator and Director of Nursing on January 21, 2026, at 1:24 PM, they both confirmed that Employee 2 should have removed her gloves, cleansed her hands, and applied clean gloves prior to administering Resident 33's medications through the gastrostomy tube.

28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services.

Plan of Correction - To be completed: 03/09/2026

Preparation and/or execution of this plan of correction does not constitute an admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. The plan of correction represents the facility's credible allegation of compliance.
One, actions taken for situation identified:
1. Employee 2 was educated on donning clean gloves and hand hygiene prior to medication administration.
Two, how the facility will respond regarding residents in similar situations:
The facility recognizes that all residents have the potential to be affected. Please see sections three and four for system changes and monitoring mechanisms.
Three, system changes and measures that will be taken:
1. All Staff will be In-serviced on proper hand hygiene and changing of gloves when going from dirty to clean procedures.
Four, monitoring mechanism to assure compliance:
1. The Director of Nursing or her designee will conduct random audits of Nursing staff 3 times per week for 1 month, then weekly for 1 month, and then monthly thereafter for compliance
2. The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings

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